Download Communicable Diseases

CHA P TE R
34
Communicable Diseases
Russell MacDonald
Vimal Scott Kapoor
INTRODUCTION
Paramedics are typically the first healthcare personnel to encounter sudden illnesses or other healthcare
emergencies in the community setting. Responding
to these emergencies puts paramedic personnel at
risk because the type, extent, and severity of this illness are not yet known. The Occupational Safety and
Health Administration (OSHA) identifies there are
more than 1.2 million community-based first response
personnel, including law enforcement, fire, and EMS
personnel, who are at risk for infectious exposure.1
This large number highlights the need to protect these
personnel against such exposures.
Although infectious and communicable disease
preparation may not have been a priority in some EMS
agencies, the 2003 severe acute respiratory syndrome
(SARS) outbreaks made it a priority. Emergency
medical personnel responding to patients at the onset
of the SARS outbreaks in Toronto2 and Taipei3 were
exposed to, or contracted, SARS in significant numbers, and one paramedic died due to SARS. More importantly, the loss of paramedic availability for work
due to exposure, illness, and quarantine impacted the
ability to maintain staffing during the outbreak and
highlighted the need for EMS systems to adequately prepare and protect the workforce from potential
exposure.4
This chapter addresses communicable and infectious disease in a manner relevant to EMS agencies and their personnel and is divided in two parts.
The first is paramedic and patient centered, describing the basics of communicable disease transmission
and prevention, general approach to the patient with
a suspected infectious or communicable disease, and
specific disease conditions outlined by presenting
complaint. The second is service- and communityoriented, describing the EMS agency’s role and planning for healthcare emergencies related to infectious
disease, EMS interactions with public health agencies, and special considerations for EMS agencies in
epidemics or pandemics.
Occupational health and safety is an important
component of infection control and prevention of
communicable disease in EMS. This includes aspects
of routine EMS operations such as immunization of
personnel, hand hygiene, personal protective equipment (PPE), sharps safety, and cleaning of equipment
and disinfection. The reader is referred to a Chapter
10, Occupational Injury Prevention and Management,
in Volume 4 dedicated to this subject.
PART 1: PARAMEDIC
AND PATIENT
Communicable Disease Transmission
and Prevention
OSHA defines an occupational exposure as “a reasonably anticipated skin, eye, mucous membrane,
or parenteral contact with blood or other potentially
infectious material that may result from the performance of the employee’s duties.”1 Infection control
practices are designed to prevent exposure to blood or
potentially infectious material, including cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
amniotic fluid, peritoneal fluid, and any other body
fluid, secretion, or tissue.
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Universal precautions is the term formerly used
to describe aspects of the methods used to prevent exposure, but this term is no longer used by healthcare
workers. The more favored terms are routine practices
and additional precautions. These terms indicate that
the same basic, minimum level of precaution is taken
for all patients.
Infection is defined by the Association for Professionals in Infection Control and Epidemiology5 as an
invasion and multiplication of microorganisms in or
on body tissue causing cellular damage through the
production of toxins, multiplication, or competition
with host metabolism. Infectious agents capable of
causing disease include bacteria, viruses, fungi and
molds, parasites, and prions. These five types of microorganisms can be differentiated by their appearance on microscopic examination, reproductive cycle,
chemical structure, growth requirements, and other
detailed criteria. Although bacteria and viruses are
the most common causes of illness in the developed
world, parasites are more prevalent in other settings.
Numerous factors are directly related to the ability
of a microorganism to cause an infection. The dose is
the amount of viable organism received during an exposure. Infection occurs when there is a large enough
number to overwhelm the body’s own defenses. Virulence refers to the ability of a microorganism to cause
infection, and pathogenicity refers to the severity of
infection. Additional factors determine the likelihood
of transmission. Incubation and communicability
period are the intervals between when the organism
enters the body and when symptoms appear, and the
time during which the infected individual can spread
the disease to others, respectively. The host status and
resistance refer to the host’s ability to fight infection,
which can be influenced by immune function and immunization status, nutritional state, and presence of
comorbid illness. (See Figure 34.1.)
An infectious disease results from the invasion of
a host by disease-producing organisms, such as bacteria, viruses, fungi, or parasites. A communicable
(or contagious) disease is one that can be transmitted from one person to another. Not all infectious diseases are communicable. For example, malaria is a
serious infectious disease transmitted to the human
blood stream by a mosquito bite, but malaria is infectious, not communicable. On the other hand, chicken
pox is an infectious disease that is also highly communicable because it can be easily transmitted from
one person to another.
The mode of transmission is the mechanism by
which an agent is transferred to the host. Modes of
transmission include contact transmission (direct, indirect, or droplet), airborne, vectorborne, or common
vehicle (e.g., food, equipment). Contact transmission
is the most common mode of transmission in the EMS
setting and can be effectively prevented using routine
practices.
Direct contact transmission occurs when there
is direct contact between an infected or colonized
individual and a susceptible host. Transmission may
occur, for example, by biting, kissing, or sexual
Causative agent
virulence
dose
pathogenicity
Modes of transmission
direct
indirect
droplet
airborne
vectorborne
bloodborne
foodborne
Susceptible host
host resistance
Portal of entry
into the body
FIGURE 34.1
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contact. Indirect contact occurs when there is passive transfer of infectious agent to a susceptible host
through a contaminated intermediate object. This can
occur if contaminated hands, equipment, or surfaces
are not washed between patient contacts. Examples
of diseases transmitted by direct or indirect contact
include human immunodeficiency virus (HIV), hepatitis, methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci (VRE),
Clostridium difficile, and Norwalk virus.
Droplet transmission is a form of contact transmission requiring special attention. It refers to large
droplets generated from the respiratory tract of a patient when he or she coughs or sneezes or during
invasive airway procedures (intubation, suctioning).
These droplets are propelled and may be deposited
on the mucous membranes of the susceptible host.
The droplets may also settle in the immediate environment, and the infectious agents remain viable for
prolonged periods of time, later transmitted by indirect contact. Examples of diseases transmitted by
droplet transmission include meningitis, influenza,
rhinovirus, respiratory syncytial virus (RSV), and
SARS.
Airborne transmission refers to the spread of infectious agents to susceptible hosts by the airborne
route. Infectious agents are contained in very small
droplets that can remain suspended in the air for prolonged periods of time. These agents disperse widely
by air currents and can be inhaled by susceptible hosts
located at some distance from the source. Examples
of diseases transmitted by airborne transmission include measles (rubeola), varicella (chicken pox), and
tuberculosis (TB).
Vectorborne transmission refers to the spread of
infectious agents by means of an insect or animal (the
“vector”). Examples of vectorborne illness include
rabies, in which the infected animal is the vector, and
West Nile Virus or malaria, in which infected mosquitos are the vectors. Transmission of vectorborne
illness does not occur between emergency personnel
and their patients.
Common vehicle transmission refers to the
spread of infectious agents by a single contaminated source to multiple hosts. This can result in
large outbreaks of disease. Examples of this type
of transmission include contaminated water sources
(Escherichia coli), contaminated food (Salmonella),
or contaminated medication, medical equipment, or
IV solutions.
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SECTION C
General Approach and Patient
Assessment
The risk of communicable disease is not as apparent as
other physical risks, such as road traffic, power lines,
firearms, or chemical agents. Paramedics and other
public service agencies must use the same level of
suspicion and precaution when approaching a patient
before the risk of communicable disease is known. The
use of routine practices, as a minimum, is necessary for
every patient encounter to mitigate this risk.
The risk assessment begins with information from
an EMS dispatch or communication center before
making patient contact. Call-taking procedures must
include basic screening information to identify potential communicable disease threats and provide this
information to all responding personnel. The screening information can identify patients with symptoms
of fever, chills, cough, shortness of breath, or diarrhea.
The call-taking can also identify if the patient location,
such nursing home, group home, or other institutional
setting, poses a potential risk to the responding personnel. This information helps responding personnel
determine what precautions are necessary before they
arrive.
When patient contact is made, personnel can
identify the patient at risk for harboring a communicable disease. A rapid history and physical examination can raise suspicion for a communicable disease.
The following screening questions help assess if the
patient has a communicable disease:
• Do you have a new or worsening cough or
shortness of breath?
• Do you have a fever?
• Have you had shakes or chills in the past
24 hours?
• Have you had an abnormal temperature
(⬎38° C)?
• Have you taken medication for fever?
A screening physical examination will also identify obvious signs or symptoms of a communicable
disease. They may include any new symptom of infection (e.g., fever, headache, muscle ache, cough, sputum, weight loss, and exposure history), as well as any
physical signs such as rash, diarrhea, skin lesions, or
draining wounds.
All personnel must take appropriate precautions
when a patient presents with any signs or symptoms
suspected to be due to an infectious or communicable
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disease. All EMS and first responder agencies must
provide appropriate training that enables personnel to
identify at-risk patients and how to use appropriate
use of PPE.
Specific Disease Conditions
by Presenting or Chief Complaint
Respiratory Infections
Respiratory infections may be suspected when there
are symptoms that classically include any combination
of cough, sneeze, shortness of breath, fever, chills, or
shakes. Infections above the epiglottis are classified as
upper respiratory tract infections, whereas those below
the epiglottis are classified as lower respiratory tract
infections. Upper respiratory infections may be suspected when patients present with “cold” symptoms
such as rhinorrhea, sneezing, lacrimation, or coryza.
More localized and possibly more serious upper respiratory may present with symptoms such as throat pain,
fever, odynophagia, dysphagia, drooling, stridor, or
muffled voice. Lower respiratory infections typically
present with fever, shortness of breath, pleural pain,
cough, sputum, and generalized symptoms such as
chills, rigors, myalgia, arthralgia, malaise, and headache. More atypical symptoms of respiratory infection
may be found in children, the elderly, and the immunocompromised. Children with respiratory infection
may present with gastrointestinal symptoms such as
nausea, vomiting, abdominal pain, and diarrhea.6,7 The
elderly and the immunocompromised may not develop
a fever in the presence of a respiratory infection.
Respiratory infections are spread when people
cough or sneeze and the aerosolized respiratory secretions directly come in contact with the mouth,
nose, or eyes of another person. Because microorganisms in droplets can survive outside the body, indirect
transmission can also occur when hands, objects, or
surfaces become soiled with respiratory discharges.
When respiratory infections are suspected in patients,
EMS providers should use droplet precautions and
apply them to a patient.
Febrile Respiratory Illness
Febrile respiratory illness should be suspected when
a patient presents with any combination of fever, new
or worse cough, and shortness of breath. It should be
emphasized that the elderly and immunocompro-
mised may not have a febrile response to a respiratory
infection.
Cough
Pneumonia
In addition to cough, shortness of breath, and fever,
patients with pneumonia may also present with additional symptoms of tachypnea, increased work of
breathing, chest or upper abdominal pain, and cough
productive of phlegm, sputum, or blood. Generalized
systemic symptoms such as myalgia, arthralgia, malaise, and headache may also be present. Gastrointestinal symptoms such as nausea, vomiting, and diarrhea
may be associated with pneumonia.8
Evidence indicates that the signs and symptoms
traditionally associated with pneumonia are actually
not predictive of pneumonia, whereas diarrhea, dry
cough, and fever are more predictive of pneumonia.
In elderly patients, the diagnosis of pneumonia is
more difficult because both respiratory and nonrespiratory symptoms are less commonly reported by this
patient group.9
Infectious agents that typically cause pneumonia include Streptococcus pneumoniae, Mycoplasma
pneumoniae, Chlamydia trachomatis, C. pneumoniae,
Pneumocystis carinii, and Haemophilus influenzae.10
The incubation period from initial contact with the
microorganism to development of symptoms is generally not well known for these organisms. For S. pneumoniae, it may be 1 to 3 days and for M. pneumoniae
may range from 6 to 32 days. P. carinii may appear
1 to 2 months after initial contact for those who are
immunosuppressed. S. pneumoniae can be transmitted
up to 48 hours after treatment is initiated. However,
M. pneumoniae can be transmissible for up to 20 days,
and the organism may remain in the respiratory tract
for up to 13 weeks post-treatment. For the other organisms, the time period when they are transmissible is
unknown.11
Pertussis
Pertussis should be in the differential diagnosis of
a patient presenting with chronic cough. Pertussis
presents in three stages: first, a catarrhal stage lasting
1 to 2 weeks, followed by a paroxysmal stage lasting
1 to 6 weeks, and finally ending with a convalescent
stage lasting 2 to 3 weeks. In the first stage, pertussis is virtually indistinguishable from any other respiratory illness because it is characterized by runny
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nose, sneezing, low-grade fever, and a mild cough.
The EMS provider may suspect pertussis in the second, paroxysmal, stage, when the patient has bursts
of rapid coughs. The cough usually ends with a long
high-pitched inspiratory effort described as a whoop,
or it may end with vomiting. The third stage is the
period of recovery, in which the cough becomes less
paroxysmal. In adolescents, adults, and the vaccinated, pertussis is milder, and hence may be indistinguishable from other respiratory illnesses, even in the
paroxysmal stage.
Pertussis is caused by the Bordetella pertussis
bacterium and transmitted by the respiratory route
with airborne droplets. Hence, respiratory and contact precautions should be undertaken with known or
suspected cases of pertussis. Unfortunately, routine
precautions are not always sufficient because pertussis is most infectious during the nonspecific catarrhal period and the first two weeks of the paroxysmal
phase. The time from infection to the development of
symptoms is usually 7 to 10 days.12
Complications from pertussis most often occur in young infants. The major complication and
most common cause of pertussis-related death is
bacterial pneumonia. From 2001 to 2003, among the
56 pertussis-related deaths reported in the United
States, 51 (96%) were among infants younger than
6 months of age.13
With the introduction of routine pertussis vaccination, pertussis had declined from about 140 cases
per 100,000 in the 1940s to about 1 per 100,000 in the
1980s. However, since the 1980s pertussis rates have
been steadily increasing. In 2002 in the United States,
there were 3 cases per 100,000. The majority of cases
were in children under 6 months of age, the age group
most at risk of pertussis-related complications.13
Children in the United States are routinely vaccinated for pertussis in a four-dose schedule, starting
at age 2 months. Because these groups are often the
source of infection in infants, an adolescent and adult
vaccine was licensed in the United States in 2005.
Pertussis is treated with macrolide antibiotics: erythromycin, clarithromycin, or azithromycin. Treatment
ameliorates the illness and decreases the communicability period. Cases of pertussis treated with antibiotics should also be isolated for 5 days after antibiotic
therapy has started to prevent further transmission. If
exposed to a patient with pertussis, the immunization
status of the contact should be assessed. In the event
that the contact is not immunized, a 7-day course with
macrolide antibiotics should be considered. Also,
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regardless of immunization status, if the contact is
a child under age 1 or a pregnant woman in the last
3 weeks of pregnancy, or if the person exposed has
contact with infants or pregnant women in the last
3 weeks of pregnancy, macrolide antibiotic prophylaxis should be offered.14
Influenza
Influenza classically presents with the abrupt onset of
fever, usually 38° C to 40° C, sore throat, nonproductive cough, myalgias, headache, and chills. Unfortunately, only about half of infected persons develop the
“classic” symptoms of influenza infection.15–17 Among
those presenting with classic symptoms, studies have
attempted to identify the signs and symptoms most
predictive of influenza. Unfortunately, these clinical
decision rules are no better than clinician judgment
alone.18
Influenza is caused by a virus with three subtypes: influenza A, B, and C. Influenza A causes more
severe disease and is mainly responsible for pandemics. Influenza A has different subtypes determined by
surface antigens hemagglutinin and neuraminidase.
Influenza B causes milder disease and mainly affects
children. Influenza C rarely causes human illness and
has not been associated with epidemics.19
Influenza transmission occurs primarily through
airborne spread when a person coughs or sneezes, but
it may also occur through direct contact of surfaces
contaminated with respiratory secretions. Hand washing and shielding coughs and sneezes help prevent
spread. Influenza is transmissible from 1 day before
symptom onset to about 5 days after symptoms begin
and may last up to 10 days in children. Time from infection to development of symptoms is 1 to 4 days.20
Influenza has been responsible for at least 31
pandemics in history. The most lethal “Spanish flu”
pandemic of 1918–1919 is estimated to have caused
40 million deaths globally, with 700,000 of those
deaths occurring in the United States in a single year.
In this pandemic, deaths occurred mainly in healthy
20- to 40-year olds, which differs from the usual
young children and elderly pattern of mortality and
morbidity in the seasonal outbreaks of influenza.
Individuals at high risk of influenza complications include young children, people over age 65, the
immunosuppressed, and those suffering from chronic
medical conditions. Complications of influenza include pneumonia, either the more common secondary bacterial pneumonia or the rare primary influenza
viral pneumonia; Reye syndrome in children taking
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aspirin; myocarditis, encephalitis, and death. Death
occurs in about 1 per 1000 cases of influenza, mainly
in persons older than age 65. Studies estimate about
36,000 influenza-related deaths annually from 1990
to 1999 in the United States.21
Influenza vaccine is the principal means of preventing influenza morbidity and mortality. The vaccine changes yearly based on the antigenic and genetic
composition of circulating strains of influenza A and
B found in January to March, when influenza reaches
its peak activity. When the vaccine strain is similar to
the circulating strain, influenza vaccine is effective in
protecting 70% to 90% of vaccinees younger than age
65 from illness. Among those aged 65 and older, the
vaccine is 30% to 40% effective in preventing illness,
50% to 60% effective in preventing hospitalization,
and up to 80% effective in preventing death. EMS
providers should be immunized annually, typically in
October.
Four antiviral drugs are available for preventing
and treating influenza in the United States. Amantadine and rimantadine belong to a class of drugs known
as adamantanes, which are active against influenza A;
oseltamivir and zanamivir belong to the class of neuraminidase inhibitors active against influenza A and B.
When used for prevention of influenza, they can be
70% to 90% effective. When used for treatment, antivirals can reduce influenza illness duration by 1 day
and attenuate the severity of illness. Antiviral agents
should be used as an adjunct to vaccination, but they
should not replace vaccination. The Centers for Disease Control and Prevention (CDC) recommends influenza antivirals for individuals who have not as yet
been vaccinated at the time of exposure, or who have
a contraindication to vaccination and are also at high
risk of influenza complications. Also, if an influenza
outbreak is caused by a variant strain of influenza not
controlled by vaccination, chemoprophylaxis should
be considered for healthcare providers caring for patients at high risk of influenza complications, regardless of their vaccination status. Since the 2005–2006
influenza season, a high proportion of influenza A viruses were resistant to the adamantanes. As a result,
the CDC has recently recommended against the use
of adamantanes for treatment and prophylaxis of influenza. The neuraminidase inhibitors continue to be
recommended as a second-line of defense against
influenza. For prophylaxis, the neuraminidase inhibitors should be taken daily until the exposure no longer
exists or until immunity from vaccination develops,
which can take about 2 weeks. For treatment, these
antivirals should be started as soon as influenza symptoms develop, but no later than 48 hours after symptoms start, and treatment should continue for 5 days.
In the setting of an influenza outbreak, EMS systems
may opt to restrict duties for EMS providers who are
not immunized or who have not yet received prophylactic antiviral therapy in attempts to prevent spread of
the outbreak.19
Avian Influenza
Influenza A virus infects humans and also can be
found naturally in birds. Wild birds carry a type of influenza A virus, called avian influenza virus, in their
intestines and usually do not get sick from the virus.
However, avian influenza virus can make domesticated birds, including chickens, turkeys, and ducks,
quite ill and lead to death. The avian influenza virus
is chiefly found in birds, but infection in humans from
contact with infected poultry has been reported since
1996. A particular subtype of avian influenza A virus,
H5N1, is highly contagious and deadly among birds.
In 1997 in Hong Kong, an outbreak of avian influenza H5N1 occurred not only in poultry, but also in
18 humans, 6 of whom died. In subsequent infections
of avian influenza H5N1 in humans, more than half
of those infected with the virus have died. In contrast
to seasonal influenza, most cases of avian influenza
H5N1 have occurred in young adults and healthy children who have come in contact with poultry infected
with, or surfaces contaminated with, H5N1 virus. As
of the end of 2007, there were 346 documented human
infections with influenza H5N1 and 213 deaths (62%).
Although transmission of avian influenza H5N1 from
human to human is rare, inefficient, and unsustained,
there is concern that the H5N1 virus could adapt and
acquire the ability for sustained transmission in the human population. If the H5N1 virus could gain the ability to transmit easily from person to person, a global
influenza pandemic could occur. No vaccine for H5N1
currently exists, but vaccine development is underway.
The H5N1 virus is resistant to the adamantanes but
likely sensitive to the neuraminidase inhibitors.22
Tuberculosis
TB is caused by the Mycobacterium tuberculosis complex. The majority of active TB is pulmonary (70%),
whereas the remainder is extrapulmonary (30%).
Patients with active pulmonary TB will typically
present with cough, scant amounts of nonpurulent sputum, and possibly hemoptysis. Systemic signs such as
weight loss, loss of appetite, chills, night sweats, fever,
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and fatigue may also be present. Clinically, the EMS
provider will be unable to distinguish pulmonary TB
from other respiratory illness; however, certain risk
factors may alert the EMS provider to the possibility of tuberculosis. These risk factors are immigration
from a high-prevalence country, homelessness, exposure to active pulmonary TB, silicosis, HIV infection,
chronic renal failure, and cancer, transplantation, or
any other immunosuppressed state.23,24
Active pulmonary TB is transmitted via droplet nuclei from people with pulmonary tuberculosis
during coughing, sneezing, speaking, or singing.
Procedures such as intubation or bronchoscopies are
considered high risk for the transmission of TB. Respiratory secretions on a surface lose the potential for
infection. About 21% to 23% of individuals in close
contact with persons with infectious TB become infected through inhalation of aerosolized bacilli. The
probability of infection is related to duration of exposure, distance from the case, concentration of bacilli
in droplets, ventilation in the room, and the susceptibility of the host exposed. Effective medical therapy
eliminates communicability within 2 to 4 weeks of
starting treatment.25
If infected with TB, an individual may develop
active TB with symptoms or latent TB, which is asymptomatic. Time from infection to active symptoms
or positive TB skin test is about 2 to 10 weeks. The
risk of developing active TB is greatest in the first
2 years after infection. Latent TB may last a lifetime,
with the risk that it may later progress to active TB.
About 10% of patients with latent TB will progress to
active TB in their lifetime.
If transporting a patient who is known or suspected of having TB, respiratory precautions should
be undertaken by the EMS provider, in particular, a
submicron mask. Patients should cover their mouths
when coughing or sneezing or wear surgical masks.
In the event of suspected exposure to a patient with
active pulmonary TB, the EMS provider should report
the case and the exposure to the EMS system or public
health authority. Close contacts should be monitored
for the development of active TB symptoms. Two tuberculin skin tests should be performed, based on public health recommendations, on those closely exposed
to patients with active TB.26 Because the incubation
period after contact ranges from 2 to 10 weeks, the
first test is typically done as soon as possible after exposure, and the second test typically is performed 8
to 12 weeks after the exposure. If the EMS provider
or contact develops either active TB with symptoms
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or latent asymptomatic TB, as diagnosed with a new
positive TB skin test, treatment should be sought.
Treatment for latent TB is typically isoniazid
(INH) for 6 to 9 months.2 This single-drug regimen is
65% to 80% effective. For active TB, a four-drug regimen (isoniazid, rifampin, pyrazinamide, and ethambutol) is typically used for 2 months. This is followed
by INH and rifampin for an additional 4 months.
Several forms of multidrug-resistant (MDR)-TB
and extensively-drug-resistant (XDR)-TB have been
identified.27 These forms require an aggressive, multidrug regimens for prolonged periods of time and are
dependent on the organism’s patterns of drug sensitivity and resistance for determination of the success
of treatment. In all cases, a physician skilled in management of TB must initiate and monitor treatment
and provide suitable follow-up. Public health officials
must also be notified.28
Severe Acute Respiratory Syndrome
It is difficult to distinguish SARS from other respiratory infections because patients present with symptoms similar to other febrile respiratory illnesses.29 On
initial presentation, reliance on respiratory symptoms
alone is not sufficient to distinguish SARS from nonSARS respiratory illness.30 Fever is the most common
and earliest symptom of SARS, often accompanied
by headache, malaise, or myalgia.31 In patients with
SARS, high fever, diarrhea, and vomiting were more
common as compared with other patients with other
respiratory illnesses.32 Cough occurred later in the
course of disease, and patients were less likely to have
rhinorrhea or sore throat as compared with other lower respiratory tract illness.33 Because clinical features
alone cannot reliably distinguish SARS from other
respiratory illnesses, knowledge of contacts is essential.34 Contact with known SARS patients, contact
with SARS-affected areas, or linkage to a cluster of
pneumonia cases should be obtained in the history.35
SARS was first recognized in 2003, after outbreaks occurred in Toronto (Canada),36 Singapore,
Vietnam, Taiwan, and China. The illness is caused by a
coronavirus. The incubation period ranges from 3 to
10 days, averaging 4 to 5 days from contact to symptom onset. About 11% of those who develop SARS
eventually die, usually due to respiratory failure. The
risk of mortality is highly dependent on the patient’s
age and presence of comorbid illnesses. The case fatality rate is less than 1% for SARS patients under
age 24 and up to 50% for those age 65 and greater or
those with comorbid illness.37
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The coronavirus is found in respiratory secretions,
urine, and fecal matter. Transmission is via droplets
spread from respiratory secretions, with high-risk
transmission during intubation and procedures that
aerosolize respiratory secretions. Transmission can
also occur from fecal or urine contamination of surfaces. There have been no confirmed cases of transmission
from asymptomatic cases. Preliminary studies show
that transmission likely occurs after the development
of symptoms, with the peak infectious period being
7 to 10 days after symptom onset, and declining to a
low level after day 23 from onset of symptoms.38
If SARS is suspected, EMS providers must use all
routine practices and additional precautions.39 EMS
systems may also elect to limit or avoid any procedures that may increase risk to EMS personnel. These
include tracheal intubation, deep suctioning, use of
noninvasive ventilatory support (continuous positive
airway pressure, bilevel positive airway pressure), administration of nebulized medication, and any other
procedure that may aerosolize respiratory secretions.
During the SARS outbreaks in Toronto, EMS medical
direction modified medical directives such that paramedics did not intubate patients or deliver nebulized
therapy in the prehospital setting.40 Finally, EMS personnel and systems must also notify the receiving facility of a patient suspected of SARS, permitting staff
to have appropriate PPE in place and a suitable isolation room prepared for the patient.41,42
Rash
Methicillin-Resistant Staphylococcus Aureus
Skin infections with onset in the community or hospital may be caused S. aureus. S. aureus is a bacterium that normally secretes beta-lactamases rendering them resistant to antibiotics such as ampicillin
and amoxicillin. Methicillin, a type of beta-lactam
antibiotic, developed in 1959, is not broken down by
these bacterial beta-lactamase enzymes. However, in
the 1960s, infections of S. aureus were found to be
resistant to methicillin and other beta-lactam antibiotics, resulting in the emergence of MRSA.43
In addition to common skin and soft tissue infections, MRSA may less commonly cause severe and
invasive infections such as necrotizing pneumonia,
sepsis, and musculoskeletal infections such as osteomyelitis and necrotizing fasciitis. MRSA skin infections
typically present as necrotic skin lesions and are often
confused with spider bites. The severity of MRSA skin
infections may range from mild to severe. Unfortunately, there are no reliable clinical or risk factor criteria to
distinguish MRSA skin and soft tissue infections from
those caused by other infectious agents.44
Initially, MRSA infections were found in patients
in healthcare facilities (healthcare-associated MRSA
[HA-MRSA]). However, community-acquired MRSA
(CA-MRSA) infections are increasingly identified
in people who did not have the traditional risk factors of those with HA-MRSA, specifically contact
with healthcare facilities. These community-acquired
strains are new MRSA strains, different from those that
cause HA-MRSA. Regardless, both HA-MRSA and
CA-MRSA can mimic infections caused by less resistant bacteria, but they are more difficult to treat.45
Transmission of MRSA is mainly through hand
contact from infected skin lesions, such as abscesses
or boils. About 1% of the healthy population is also
colonized with MRSA, mainly in the anterior nares,
but also in the pharynx, axilla, rectum, and perineum.
Therefore, autoinfection may also be a route of infection. The transmissible period lasts as long as skin lesions continue to drain or as long as the carrier state
remains. Newborns, the elderly, and the immunosuppressed are most susceptible.
Transmission of infection is prevented by routine
precautions. Draining wounds should be covered with
clean, dry bandages. Contaminated surfaces should
be cleaned with disinfectants effective against S. aureus, such as a solution of dilute bleach or quaternary
ammonium compounds. One study has showed that
EMS ambulances may have a significant degree of
MRSA contamination, highlighting the need for proper cleaning and decontamination of all equipment and
the vehicle itself after every patient transport.46
There are no data to support the routine use of decolonization of MRSA with antiseptic agents or nasal
mucopirocin. Decolonization may be considered in select circumstances, when a person has multiple recurrent
infections of MRSA, or there is ongoing transmission
in a well-defined group of close contacts. Little data are
available on effective decolonization agents, but topical chlorhexidine gluconate or diluted bleach (3.4 g of
bleach diluted in 3.8 L of water) is suggested.47
In those with skin or soft tissue infections, any
drainage should be cultured. Abscesses should be
incised and drained. Antibiotic therapy may be considered if there are signs of cellulitis, systemic illness, associated immunosuppression, extremes of
age, facial infection, or failure of initial incision and
drainage.The choice of therapy should be dictated by local
susceptibility patterns. Clindamycin, doxycycline, and
trimethoprim-sulfamethoxazole (TMP-SMX) are con-
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siderations for treatment of CA-MRSA skin and soft
tissue infections. HA-MRSA may be resistant to many
more classes of antibiotics, and vancomycin or linezolid
may be necessary.48
Measles
Measles is a viral disease that initially presents with a
2- to 4-day prodrome of fever, cough, runny nose, and
possibly conjunctivitis. In the prodrome stage, the EMS
provider will be unable to clinically distinguish measles from any other viral upper respiratory illness. A
measles rash follows, beginning on the hairline, then involving the face and neck, and over 3 days, proceeding
downward and outward to the hands and feet. The rash
produces discrete red maculopapular (flat and raised)
lesions initially, which may become confluent. Initially,
the lesions blanch, and after 3 to 4 days they become
nonblanchable spots, which appear within 1 to 2 days
before or after the maculopapular rash. Koplik spots,
punctate blue-white spots on the red buccal mucosa of
the mouth, are pathognomonic for measles and would
alert the EMS provider to the presence of measles.49,50
Measles has a 0.2% mortality rate, mainly due to
pneumonia in children in developing countries. Cases
of measles have declined dramatically since the introduction of live attenuated virus vaccine in 1963, with
a record low of 34 cases in 2004. Sporadic outbreaks
occur in populations that refuse vaccination. Children in United States are routinely vaccinated with
two doses of measles vaccine (MMR) at ages 12 to
15 months and ages 4 to 6 years.
Measles is transmitted by aerosol or droplet
spread and is communicable from 4 days before appearance of the rash to 4 days after rash appearance.
EMS providers will likely encounter the patient in the
transmissible stage and should use routine practices
to prevent spread of disease.
The incubation period is approximately 10 days.
Those who have not been immunized or have never
acquired measles (born after 1957) are susceptible to
infection if exposed. If susceptible and exposed, immunoglobulin should be given to children under age
1, pregnant women, and the immunocompromised
within 6 days of exposure. For other susceptible persons, live measles vaccine may prevent disease if given within 72 hours of exposure. There is no treatment
for measles, but vitamin A supplementation should be
considered to prevent ocular complications.51,52
Rubella
Rubella is a viral disease with a prodrome that precedes
the rash. Clinical diagnosis alone is unreliable. The pro-
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drome consists of fever, upper respiratory symptoms,
and prominent lymphadenopathy, lasts 1 to 5 days, and
is mostly present in older children and adults. During
the prodrome, rubella is clinically indistinguishable
from any other viral upper respiratory tract infection.
A maculopapular rash, appearing 14 to 17 days after
exposure and lasting 3 days, typically follows the prodrome. Like measles, the rash starts on the face and
progresses downward. In contrast to a measles rash, the
rash due to rubella is fainter, does not coalesce, and is
more prominent after a hot shower or bath. Associated
symptoms may include arthralgias or conjunctivitis.
Confirmation of rubella infection is by laboratory diagnosis of virus or antibody.53
Rubella is transmitted from respiratory secretions
via airborne transmission or droplet spread, with an
incubation period of 14 to 17 days. Even though rubella is most contagious when the rash is present, it
may be transmitted by subclinical or asymptomatic
cases of rubella and up to 7 days before the onset of
rash.
Life-threatening complications of rubella include encephalitis and hemorrhage, but these are
uncommon. The main objective of immunization is
to prevent congenital rubella syndrome (CRS), the
main complication of rubella. CRS occurs when a
pregnant woman in early gestation, mainly in the first
trimester, is exposed to rubella. CRS may lead to fetal death, premature delivery, and congenital defects
including deafness and ocular, cardiac, and neurologic abnormalities.
There is no specific treatment for rubella, only
preventative vaccination. Rubella immunization is
part of the routine childhood vaccinations, administered as a live vaccine along with measles and mumps
as MMR. Infants born to mothers immune to rubella
are protected for 6 to 9 months from transplacental
maternal antibodies.54
If exposed to patients later diagnosed with rubella, immunity of the contact should be assessed.
Subsequent immunization of the nonimmunized contact would not prevent infection or illness. In adults,
rubella is generally a mild febrile disease, and control
measures are aimed at preventing spread to nonimmunized pregnant women. In the case of spread, patients suspected of having rubella should be isolated
with routine precautions. Pregnant women contacts
should be investigated for immunity. In case of infection with rubella in nonimmune pregnant women in
early pregnancy, counseling should be provided with
consideration for abortion. Immunoglobulin in early
pregnancy may also be given to modify or suppress
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symptoms, but there have been cases of CRS despite
immunoglobulin therapy.55–57
Varicella
Like measles and rubella, varicella starts with a prodrome that subsequently leads to a rash. In children,
the prodrome of fever and malaise may be absent.
Unlike measles and rubella, varicella infection, or
chicken pox, can be clinically diagnosed by the EMS
provider based on a more pathognomonic rash. The
pruritic rash progresses from macules to papules and
then to vesicles that later crust over. The vesicles are
unilocular and collapsible, in contrast to the multilocular and noncollapsible vesicles of smallpox. Lesions
start on the scalp, progress to the trunk, and later
move to the extremities.58
Varicella virus infection leading to chicken pox
typically lasts 3 to 4 days, with an incubation period
of 14 to 16 days. Transmission is by airborne droplets
from the respiratory tract or by inhalation of aerosolized vesicular fluid from skin lesions. Chickenpox is
transmissible 1 to 2 days before the onset of rash until
all papules become crusted.59
Complications in children include secondary
bacterial skin infections, pneumonia, and dehydration. Nonimmunized adults may have more severe
complications, including encephalitis, transverse myelitis, hemorrhagic varicella, and even death. In the
United States, only 5% of the reported cases of varicella
are from adults, whereas 35% of the mortality occurs
in adults. The case fatality rate is 1 per 100,000 cases
in children aged 1 to 14, but 25.2 per 100,000 cases in
adults aged 30 to 49 years of age.
Maternal varicella 5 days before to 48 hours after
delivery may result in neonatal infection and subsequent mortality as high as 30%. Varicella infection
in the mother at 20 weeks of gestation can lead to
congenital varicella syndrome, which includes skin
scarring, extremity atrophy, and eye and neurologic
abnormalities.
Since the licensure of varicella vaccine in 1995 in
the United States, cases of chickenpox have declined
by 83% to 94% by 2004. Varicella vaccine is recommended for all children without contraindication at
12 to 18 months of age and is administered as one
dose. Adults and adolescents age 13 years and older
who do not have evidence of immunity should receive
two doses of varicella vaccine.
Cases of chicken pox should be excluded from
public places until the vesicles become dry. In the
hospital, strict isolation measures should be undertaken to avoid contact with susceptible immunocom-
promised persons. Articles soiled by discharges from
the nose and throat should be disinfected.
If exposed to chickenpox, contacts should assess
their susceptibility based on their immune status. If
previously infected or vaccinated, contacts are immune. Susceptible nonimmune contacts have three
choices to prevent infection: vaccination, varicella
zoster immunoglobulin, or antiviral drugs. Varicella
vaccine can prevent illness or attenuate severity if
used within 3 days of contact. Vaccine is recommended in susceptible individuals. Varicella zoster immunoglobulin (VZIG) is recommended for newborns,
the immunocompromised, and pregnant women and
can also modify severity or prevent illness if given
within 96 hours of exposure. Antiviral drugs such as
acyclovir, if used within 24 hours of onset of rash,
can reduce the severity of disease. These are not recommended for routine postexposure prophylaxis, but
they can be considered in persons aged older than
13 years and the immunocompromised.60,61
Bites
Bites require treatment for the physical injury itself
and treatment for the infectious disease exposure due
to the bite. Infection rates from bites mainly depend
on the animal that has caused the bite and the site of
injury.62 Cat bites can have an infection rate of up to
50%, whereas about 10% of dog bites become infected. Bites on the face, scalp, hand, wrist, foot, or
joints have the highest rate of infection. Hands are
the most common site of human, dog, and cat bites.
Bite infections may cause cellulitis, osteomyelitis, abscess, septic arthritis, or even septicemia. In addition
to antibiotic therapy, bites may also require treatment
with rabies prophylaxis, tetanus prophylaxis, HIV
prophylaxis, and hepatitis B prophylaxis. Prophylactic
antibiotic treatment for bites depends on the specific
infectious agents most commonly associated with the
particular animal. Finally, EMS personnel should also
be aware of the risk of transmission of hepatitis C due
to human bites.63
Animal Bites
Bites by dogs and cats account for 95% of animal bites.
In up to 75% of infected cat bites and 50% of infected
dog bites, the causal infectious agent is Pasteurella
species. This bacterium can produce an infection in
as short as 12 hours. P. canis is the most common organism in infected dog bites, whereas P. multicoda is
most common in cat bites. Other common organisms
from infected cat and dog bites include Streptococci,
Staphylococci, Fusobacterium, and Bacterioides.62
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Preventing infection due to bites should begin
with copious high-pressure irrigation with sterile saline solution. Prophylactic antibiotics are advised for
hand bites from cats or dogs and high-risk bites including any cat bite, deep dog bite punctures, and bites
in immunocompromised individuals. Amoxicillinclavulanic acid or cefuroxime, each for 5 days, provides appropriate broad-spectrum activity. In penicillin-allergic patients, either azithromycin alone or
clindamycin with levofloxacin can be given.64,65
Human Bites
After dog and cat bites, humans are the next most
common cause of bites. Streptococci species and
Eikenella corrodens are the most common pathogens in infected human bites. Clenched-fist injuries,
resulting from a flexed knuckle of a fist striking human teeth, are common and serious causes of human
bite injuries. This type of injury often leads to serious
deep infections because the patient usually offers an
alternative mechanism for the hand injury, resulting
in delayed antibiotic therapy. Human bites can also
transmit HIV, hepatitis B, and hepatitis C.66
Prophylactic antibiotics should be provided for all
human bites that penetrate deeper than the epidermal
layer, as well as bites to the hands, feet, or skin overlying joints or cartilaginous structures. Amoxicillinclavulanic acid for 5 days is recommended as prophylactic therapy for human bites. In penicillin-allergic
patients, a combination of clindamycin and a fluoroquinolone is a suggested regimen. Postexposure prophylaxis (PEP) for HIV and hepatitis B should be considered for human bites according to a risk evaluation
of the source. Patients should also be educated on the
risk of transmission of hepatitis C.67
Rabies
Rabies is caused by rabies virus, a rhabdovirus of the
genus Lyssavirus, and may be transmitted by an animal bite. There is no treatment for rabies once it develops, and it has a mortality rate approaching 100%.
The time from infection to development of disease is
usually 3 to 8 weeks, and death is typically due to
respiratory paralysis. To determine the risk of rabies
transmission, knowledge is needed on the type of animal inflicting the bite, geographic location of the incident, the vaccination status of the animal and person,
whether the bite was provoked or unprovoked, and
whether the animal can be captured and tested.68
Patients receiving bites by animals suspected of
having rabies should be given PEP. For nonimmune in-
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dividuals, prophylaxis consists of one dose of human
rabies immunoglobulin, half given into the bite site,
accompanied by a five-dose series of rabies vaccine on
days 0, 3, 7, 14, and 28. PEP should always occur in
consultation with local public health officials.69
In the United States in 2006, 92% of rabid animals
were wild, and 8% were domestic. Among wild animals, rabies was most frequently found in raccoons,
followed by bats, skunks, and foxes. Among domestic
animals, cats were the most common cause of rabies,
followed by dogs and cattle. Squirrels, guinea pigs,
hamsters, chipmunks, gerbils, mice, rats, rabbits, and
hares very rarely have rabies. In the United States,
there have been two to three cases of human rabies
each year for the last 10 years. Most were due to contact with bats, likely because bites from bats are superficial and not easily noticed. In the United States,
Canada, and Western Europe, dogs account for less
than 5% of animal rabies, whereas in most developing
countries, dogs account for more than 90% of cases of
animal rabies.
Rabies immunization is not routinely recommended for the general population in North America, unless the person is engaged in activities that place him
or her at high risk of acquiring rabies. These include
rabies lab workers and veterinarians. Most agencies
recommend that domestic dogs, cats, ferrets, and livestock be vaccinated against rabies. Routine rabies immunization for EMS personnel is not recommended.
Abnormal behavior in an animal or an unprovoked bite is more likely to indicate that a bite was
from a rabid animal. This increases the risk of rabies
transmission, and PEP should be offered. If a dog, cat,
or ferret that caused a bite can be captured, it should
be confined and observed for 10 days for the development of rabies symptoms. If rabies develops, the bitten individual should receive rabies PEP. For any bites
from bats, raccoons, skunks, or foxes, PEP should be
offered regardless of whether the animal is captured
or not.70,71
Tetanus
Bites are at risk of being infected with C. tetani because they are puncture wounds and/or contaminated
with saliva. Live C. tetani organisms are not present
in the oral flora or humans or animals, but their resilient spores are ubiquitous in the environment, soil,
and feces. Crushed, devitalized tissue produced by
bites favors the production of tetanus.72,73
Tetanus is an often fatal disease caused by the
exotoxin of C. tetani. The incubation period ranges
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from 3 to 21 days, during which time the spores
transform into live bacteria which then produce an
exotoxin. Clinically, the exotoxin leads to convulsive spasms of the skeletal muscles and generalized
rigidity, mainly involving the jaw and neck. Patients
with any form of bites should receive prophylaxis
with 0.5 ml of tetanus toxoid intramuscularly if they
have not been immunized within the past 5 years.
Those who have not completed a primary immunization series, or have an unknown immunization
history should also receive tetanus immunoglobulin.74
Meningitis
Meningitis refers to inflammation of the meninges covering the brain. It can be caused by infectious and noninfectious causes. Noninfectious causes include drugs,
vaccines, systemic disease such as collagen vascular
disorders, and malignancy. Infectious causes include
viruses, bacteria, fungi, parasites, and rickettsiae.75
Meningitis is typically classified as bacterial meningitis versus aseptic meningitis. Aseptic meningitis
refers to meningitis with cerebrospinal fluid absent of
microorganisms on Gram stain and/or routine culture.
The most common cause of aseptic meningitis is viral
agents.76,77 Viral meningitis is generally less severe,
and requires supportive measures with no specific
treatment. Bacterial meningitis, on the other hand,
has a case fatality rate of 13% to 37%, and as high
as 80% in the elderly, despite appropriate antibiotic
therapy. In addition, up to 20% of survivors of bacterial meningitis have permanent sequelae such as brain
damage, hearing loss, or limb loss.78,79
Bacterial meningitis should be suspected when the
patient presents with at least two of the four following
symptoms: headache, fever, neck stiffness, or altered
mental status. However, the EMS provider should be
aware that only one of these symptoms may be present
in the patient with bacterial meningitis.80 Focal neurologic symptoms, such as extremity pain or temperature
changes, may be early signs. Although a petechial rash
is classically associated with bacterial meningitis, only
11% to 23% of patients with bacterial meningitis actually have a rash.81 In the absence of diagnostic tests
such as lumbar puncture, EMS personnel are unable to
use clinical signs and symptoms alone to distinguish
bacterial from aseptic meningitis.82–84 Considering the
rapid onset of symptoms and high morbidity and mortality with untreated bacterial meningitis, all patients
with suspected meningitis should be treated as bacterial meningitis until proven otherwise.
Neisseria meningitidis and S. pneumoniae
currently account for 80% to 85% of adult community-acquired meningitis. Less common causes
include staphylococci, group B streptococci, and
Listeria. S. pneumoniae is a more common cause
of meningitis, and mortality is also higher (30%) as
compared to the mortality rate of meningitis caused
by N. meningitidis (7%). Since the introduction of
routine childhood vaccination with H. influenzae
type b, this is no longer a leading cause of meningitis.85–87
Transmission is by droplet spread from respiratory secretions. Therefore, respiratory and contact
precautions should be undertaken when transporting
patients suspected of meningitis. The time from transmission to the development of symptoms is about 2 to
10 days for N. meningitidis and about 1 to 4 days for
S. pneumoniae.
Empiric treatment of adult bacterial meningitis
is vancomycin plus a third-generation cephalosporin,
such as cefotaxime. In neonates, those over age 50,
and those with altered immune status or alcoholism,
ampicillin is added to cover L. monocytogenes. Treatment may last 14 to 21 days depending on the infectious agent. In addition to treating the patient, EMS
personnel exposed or in close contact with patients
with meningitis may require prophylactic therapy.
This is particularly important for personnel exposed
to the patient’s oral or respiratory secretions. Exposed
personnel should contact their EMS agency or local
public health agency immediately. Public health will
likely provide prophylactic treatment with ciprofloxacin, ceftriaxone, or rifampin to prevent infection due
to close contact.88
Diarrhea
Diarrhea is practically defined by increased frequency, increased volume, and decreased consistency of
stools. A strict definition is greater than three stools in
a 24 hour period, with the stools being liquid enough
to adopt the shape of the container in which they are
placed. Acute diarrhea lasts up to 2 to 3 weeks, with
chronic diarrhea lasting longer. Infectious diarrhea is
commonly associated with nausea, vomiting, fever,
abdominal cramps, and intestinal gas-related complaints. Diarrhea may be infectious or noninfectious
in origin, and the provider should attempt to rule out
noninfectious causes because most noninfectious
causes are true diarrheal emergencies (e.g., mesenteric ischemia, gastrointestinal bleed, and bowel obstruction).
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Infectious diarrhea may be caused by viruses,
bacteria, protozoa, or helminthes. The diarrhea may
be caused by the organisms themselves or the toxins
they produce. Gastrointestinal infections are typically
spread by contaminated water, contaminated food,
contaminated environments, direct contact among
humans, and hand-to-mouth transmission. The differential diagnosis can be narrowed by selectively
testing stool specimens for bacterial culture, ova, parasites, C. difficile toxin, and viral enzyme-linked immunosorbent assay (ELISA) tests. These tests are not
available in the prehospital setting, but history may
identify prior testing results and the likely offending
agent.89
To prevent spread of infection, EMS providers
and systems must ensure routine practices and additional precautions are in place. In addition, equipment
and transport vehicles must be thoroughly cleaned
and decontaminated when transport involves a patient
suspected of having infectious diarrhea.
Therapy that can be initiated by EMS providers
includes isotonic fluid replacement and management
of hypovolemia and sepsis. Antibiotic therapy and antimotility therapy should only be considered once a
thorough assessment has been conducted in the hospital setting because there are certain diarrheal conditions in which such therapy may be inappropriate.
Acute infectious diarrhea may be bloody or watery, with bloody diarrhea signifying inflammatory
destruction of the intestinal mucosa. Whether the diarrhea is watery or bloody provides clues as to the
cause of the diarrhea and the consequent sequelae:
In watery diarrhea, the main concern is dehydration,
whereas in bloody diarrhea, the main concern is intestinal damage and sepsis.89
The most common causes of diarrhea are viruses,
accounting for 50% to 75% of cases. As compared
with bacterial diarrhea, viral diarrhea typically has
less high fever and watery stools, whereas bacterial
diarrhea typically has bloody stools with less severe
abdominal pain. Among the viral causes of diarrhea,
rotavirus90 and the noroviruses91 (Norwalk and Norwalk-like viruses) account for 50% of viral gastroenteritis. Adenoviruses are the second most common
cause of acute viral gastroenteritis. Rotavirus diarrhea
is the most common cause of viral diarrhea in children
and usually occurs in children between 6 and 24 months
of age because most individuals have antibodies by
age 3. History and physical examination alone cannot clinically distinguish rotavirus from other enteric
viral infections because rotavirus infection presents
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with watery diarrhea, vomiting, fever, and abdominal
pain. It is usually diagnosed from rotavirus antigen
in stools. In addition to transmission by the contact
and the fecal-oral route, respiratory spread may also
occur with rotavirus. The incubation period is 24 to
72 hours, with the period of communicability being
up to 8 days from the start of the watery diarrhea. Two
rotavirus vaccines are available for children, RotaRix
and Rotateq; Rotateq is licensed for use in the United
States. In 1999, RotaShield was withdrawn from the
market after being associated with intussusception.
Diarrhea by norovirus causes signs and symptoms clinically indistinguishable from rotavirus: nausea, vomiting, diarrhea, and abdominal pain also occur with norovirus infection. In children, vomiting is
more prevalent, whereas in adults, diarrhea is more
common. Diagnosis is made by nucleic acid hybridization assays and reverse transcriptase-polymerase
chain reaction (RT-PCR). The incubation period is
12 to 48 hours, and illness lasts for a shorter time than
rotavirus diarrhea, 12 hours to 3 days. The period of
communicability is unknown, lasting up to 7 days.
Transmission routes are similar to rotavirus, including airborne transmission. There is currently no vaccine for norovirus infections.91
Bacterial diarrhea typically includes bloody diarrhea, as opposed to watery diarrhea; however, not
all bacterial diarrhea is bloody. Bloody diarrhea is
often referred to as dysentery. It is important to note
that bloody diarrhea may not necessarily be due to
infectious causes, and other causes of bloody diarrhea should be considered, such as mesenteric ischemia or other non-infectious conditions producing
gastrointestinal bleeding. Common causes of bacterial diarrhea are Salmonella, Shigella, Yersinia,
E. coli, and Campylobacter.92,93
E. coli are classified by their O, H, and K antigens and also by their virulence properties.94 E. coli
0157:H7 is the main serotype that causes bloody diarrhea through secretion of a potent shiga-like cytotoxin. This serotype was responsible for a large outbreak of bloody diarrhea in the United States in 1982.
This bloody diarrhea is notable for the absence of
fever and the subsequent 5% to 15% rate of development of hemolytic uremic syndrome (HUS), manifesting as pallor, jaundice, scleral icterus, dark urine,
purpura, mucosal bleeding, dyspnea, and chest pain.
The death rate of infections that lead to HUS is 3%
to 5% even with intensive care unit treatment. E. coli
0157:H7 is found in healthy cattle and is spread to humans from undercooked beef, raw milk, and produce.
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The incubation period is typically 3 to 4 days, and the
period of communicability can be up to 3 weeks in
children. Antibiotics and antimotility agents are not
recommended for this infection. Treatment is directed
at HUS, which may require dialysis, steroids, or plasma therapy in the intensive care unit setting.
C. difficile is a bacterium that can cause a spectrum
ranging from mild watery diarrhea to severe colitis,
which may progress to perforation of the colon and
sepsis.95–97 This infection is increasing in prevalence
and frequently associated with healthcare settings.95
More than 90% occur after or during antibiotic therapy.
C. difficile is also the most common cause of bacterial diarrhea in persons with HIV in the United States.
The EMS provider may only suspect diarrhea associated with C. difficile based on the risk factors because
it is clinically indistinguishable from any other watery
diarrhea based on signs and symptoms. Diagnosis is
confirmed by enzyme immunoassays of stool samples.
EMS providers should notify transfer and receiving
facilities that a patient has disease associated with
C. difficile, if known. Treatment is cessation of existing antibiotic therapy if possible, rehydration, avoidance of antimotility agents, and therapy with oral
metronidazole or vancomycin for 10 days.98
Jaundice
Hepatitis A
Hepatitis A can cause acute disease or asymptomatic infection but not chronic infection.99 Whereas
more than 70% of older children and adults are
symptomatic, in children younger than 6 years,
70% of infections are asymptomatic. Symptomatic
illness is characterized by fever, jaundice, and dark
urine, in addition to malaise, anorexia, and nausea.
Jaundice is the most common symptom. Unfortunately, the clinical signs and symptoms of hepatitis
A are indistinguishable from other types of acute
viral hepatitis. Diagnosis is usually made by immunoglobulin detection in blood: anti-hepatitis A immunoglobulin M in the acute phase, and anti-hepatitis A immunoglobulin G after 6 months.
Hepatitis A infection rarely progresses to fulminant hepatitis A, which can lead to death. In 2005,
0.6% of patients with hepatitis A progressed to fulminant hepatitis and died. Age and underlying chronic
liver disease are risk factors for progression to fulminant hepatitis. Also in 2005, the proportion of persons
hospitalized with hepatitis A increased with age from
20% among children aged less than 5 years to 47%
among persons aged greater than 60 years.
Hepatitis A is transmitted by the fecal-oral route
from consumption of contaminated food or water.
Rarely, hepatitis A can be transmitted by blood transfusion, particularly clotting factor concentrates. In the
United States between 1990 and 2000, 45% of hepatitis A patients could not identify a risk factor for their
infection. The time from infection to the presentation
of symptoms, if any, is on average 28 days. Hepatitis
A is most transmissible from feces 1 to 2 weeks before the onset of illness to about 1 week after the onset
of jaundice.
If an EMS provider comes in contact with a patient suspected of having hepatitis A, routine practices and additional precautions can prevent spread
of infection. Hepatitis A infection is prevented
with vaccination administered in two doses 6 to
18 months apart. In 2005, the Advisory Committee
on Immunization Practices (ACIP) recommended
that all children aged 12 to 23 months of age receive
the hepatitis A vaccination. International travelers,
men who have sex with men, persons with clotting
factor disorders, and those with chronic liver disease should also be immunized. Hepatitis A vaccination is not routinely recommended for healthcare
workers.
Unvaccinated persons who have been exposed to
hepatitis A may be candidates for postexposure antihepatitis A immunoglobulin. This has been shown to
be 85% effective in preventing hepatitis A infection
if given within 2 weeks of exposure. Potential candidates include persons who have had household or
sexual contact with a person with hepatitis A, persons who have shared illegal drugs with a person with
hepatitis A, food handlers working with another food
handler diagnosed with hepatitis A, patrons of an infectious food handler if the food handler had diarrhea
or poor hygiene, and staff and attendees at a child care
center where a hepatitis A case has been diagnosed.
Vaccination should supplement immunoglobulin administration in PEP but not replace it.100–102
Hepatitis B
Hepatitis B infection can cause acute disease, chronic disease, or be asymptomatic.103 Like hepatitis A,
symptoms present more in adults than children, and
symptoms are not specific for hepatitis B. Even about
50% of adults with acute infection are asymptomatic.
When symptoms occur, they are divided into phases:
prodromal, icteric phase, and convalescent phases. In
the 3- to 10-day prodromal phase, nonspecific symptoms of malaise, weakness, and anorexia are the most
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common symptoms, but also low-grade fever, arthritis,
rash, vague abdominal discomfort, nausea, and vomiting may occur. The icteric phase lasts 1 to 3 weeks
and is characterized by jaundice, dark urine, and light
stools starting 1 to 2 days before the onset of jaundice. In convalescence, jaundice disappears, whereas
malaise and fatigue may persist for weeks. Definitive
diagnosis of hepatitis B is by serologic testing.
Most acute hepatitis B infection results in complete recovery, but in 1% to 2% of patients fulminant
hepatitis infection occurs, with a 63% to 93% case
fatality rate. About 10% of acute infections progress
to chronic infection, which leads to premature death
from cirrhosis or liver cancer in 25% of cases. In the
United States, an estimated 46,000 new hepatitis B
infections occurred in 2006.
Hepatitis B is transmitted by percutaneous or
mucosal exposure to infected blood or blood products.
Transmission can also occur from saliva, semen, vaginal secretions, and cerebrospinal, pleural, peritoneal,
pericardial, amniotic, or synovial fluid. Transmission
to EMS workers can occur not only from needlesticks
or other sharp injuries but also through cutaneous
scratches or abrasions. The hepatitis B virus can exist for at least 7 days outside the body on inanimate
surfaces, and infection can occur by touching skin lesions or mucous membranes with any contaminated
equipment. This is particularly important in the EMS
setting and emphasizes the need for adherence to routine practices and additional precautions and proper
cleaning and decontamination of equipment and
vehicle surfaces. If the hepatitis B HBs-antigen is
present in the blood of a source, then the source is
communicable for hepatitis B. If infected, the incubation period is on average 60 to 90 days.
Hepatitis B vaccination is recommended for all
infants at birth, age 1 to 2 months, and at age 6 to
18 months. For unvaccinated adults, a three-dose
schedule is recommended for those at increased risk
of hepatitis B infection, which includes healthcare
workers.
If percutaneous or mucous membrane exposure
occurs to blood that may contain hepatitis B, PEP with
hepatitis B immunoglobulin may be considered. Before doing so, the vaccination status of the exposed
person with hepatitis B should be assessed. If vaccinated, the exposed person should have an assessment
of protective antibody levels to hepatitis B because
about 5% of vaccinees may not respond to the hepatitis
B vaccine. If available, the source blood should also be
assessed for the presence of HBs-antigen, which signi-
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fies infection with hepatitis B and communicability. If
an individual is exposed to HBsAg-positive fluid and
is nonimmunized or lacks protective antibody levels,
hepatitis B immunoglobulin should be given within
24 hours, and hepatitis B vaccination also should be
started.104–106
Hepatitis C
About 60% to 80% of persons infected with hepatitis
C are initially asymptomatic. Among the 15% to 30%
who become symptomatic, clinical signs and symptoms are similar to those of other acute viral hepatitis illnesses and include jaundice, fatigue, dark urine,
abdominal pain, anorexia, and nausea. Diagnosis of
hepatitis C is by serologic testing.107
Unlike the other viral hepatitis infections, in up to
85% of hepatitis C infections, persistent infection develops. Among those with chronic infection, 70% develop
chronic liver disease, and 1% to 5% of those die prematurely from their chronic liver disease. It is estimated
that 19,000 new hepatitis C infections occurred in the
United States in 2006, and 3.2 million U.S. Americans
are chronically infected with hepatitis C.
Hepatitis C is transmitted by mucosal or percutaneous exposure to infectious blood or blood-derived
body fluids. Sexual contact can lead to transmission
but is a far less efficient route of transmission. The
period of transmission may persist in infected persons
indefinitely. If infected, the incubation period is on average 6 to 9 weeks, and it may take up to 20 years
before the onset of liver disease.
There is no vaccine available to prevent hepatitis C, and PEP with hepatitis C immunoglobulin has
not been shown be effective. EMS providers must
rely on routine practices and additional precautions to
prevent occupational and nosocomial transmissions.
Disposable injection equipment should not be reused
and should be properly disposed of, and reusable injection equipment should be appropriately sterilized
before reuse.108,109
Biologic Weapons
Anthrax
The symptoms of anthrax are determined by the route
of transmission of the bacterium that causes anthrax,
Bacillus anthracis. There are three forms of anthrax:
cutaneous, gastrointestinal, and inhalational.110,111
Cutaneous anthrax presents as a small, painless,
pruritic papule, which progresses to an enlarging vesicle
in 1 to 2 days. The vesicle ruptures and erodes, leaving a
necrotic ulcer that later gets covered with a black, pain-
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less eschar. Pathognomonic features of anthrax include
the presence of an eschar, lack of pain, and edema out
of proportion to the size of the lesion. Associated symptoms include swelling of adjacent lymph nodes, fever,
malaise, and headache. Cutaneous anthrax is caused by
B. anthracis entering a cut or abrasion in exposed areas
of the body such as the face, neck, arms, and hands. The
incubation period of cutaneous anthrax is 1 to 12 days.
The case fatality rate can be as high as 20% without
antibiotic therapy, but lowers to 1% with therapy.
Gastrointestinal anthrax presents with more nonspecific symptoms. Two forms exist: oropharyngeal
and intestinal. Oropharyngeal anthrax starts with
edematous lesions at the base of the tongue or tonsils
that progress to necrotic ulcers with a pseudomembrane. Sore throat, fever, cervical adenopathy, and
profound oropharynx edema are associated symptoms.
This form of anthrax initially presents with fever, nausea, vomiting, and abdominal pain and tenderness that
may progress to hematemesis, bloody diarrhea, and
abdominal swelling from hemorrhagic ascites. Gastrointestinal anthrax is caused by consumption of meat
contaminated with anthrax. The incubation period for
intestinal anthrax is believed to be 1 to 7 days. The
case fatality rate of gastrointestinal anthrax is estimated to be 25% to 60%.
Inhalational anthrax initially causes nonspecific
symptoms that mimic influenza. These early symptoms are low-grade fever, nonproductive cough,
malaise, and myalgias. Two to 3 days later, the patient rapidly progresses to severe dyspnea, profuse
sweating, high fever, cyanosis, and shock. Hemorrhagic meningitis occurs in up to half of patients. It
is critical that the EMS provider attempt to distinguish any influenza-like illness from anthrax because
of the narrow window opportunity for successful
treatment. Nasal congestion and rhinorrhea are not
common with inhalational anthrax but more common with influenza-like illness. Further, shortness of
breath is more common in inhalational anthrax and
less common in influenza-like illness. Although not
typically available to EMS providers, the chest x-ray
demonstrates mediastinal widening or pleural effusion. These findings are the most accurate predictors
of inhalational anthrax. Inhalational anthrax can be
caused by inhalation of anthrax spores, commonly
seen following intentional release of aerosolized
anthrax, or from the processing of materials from
infected animals, such as goat hair. The incubation
period for inhalational anthrax is usually 1 to 7 days
but can be as long as 43 days. Case fatality rate of
inhalational anthrax can be as high as 97% without
antibiotics and up to 75% with antibiotics.
Human-to-human transmission of any form of
anthrax is rare. A vaccine for anthrax is licensed in
the United States and is administered in a six-dose
schedule with annual boosters thereafter. Vaccination
is not currently recommended for emergency first responders or medical personnel; however, it may be
indicated for certain military personnel. In cases of
deliberate use of anthrax as a biologic weapon, first
responders should wear a full face respirator with
high efficiency particulate arresting (HEPA) filters
or a self-contained breathing apparatus, gloves, and
splash protection. If clothing is contaminated, it should
be removed and placed in plastic bags. Soap and
copious amounts of water should be used to decontaminate skin, and bleach should be applied for
10 to 15 minutes in a 1:10 dilution if there is gross
contamination. If exposure to aerosolized anthrax occurs, PEP with ciprofloxacin or doxycycline should
begin and continue for 60 days. Vaccination given
in three doses for PEP should also be administered
because of the persistence of anthrax spores in the
lungs. Quarantine is not appropriate for persons exposed to anthrax because they are not contagious. Patients suspected of being infected with anthrax and requiring hospitalization should be immediately started
on IV antibiotics such as ciprofloxacin and one other
active drug. Other active drugs include doxycycline,
rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, and clindamycin. Treatment
should continue for 60 days or longer.112–114
Botulism
Botulism is caused by a neurotoxin produced by
C. botulinum, which ultimately leads to a flaccid paralysis. Four clinical forms of botulism exist, and the presenting form is based on the site of toxin production:
foodborne, wound, intestinal, and inhalational.115
In foodborne botulism, early symptoms are nonspecific gastrointestinal ones, and they include nausea,
vomiting, and diarrhea. This may progress to blurred
vision, double vision, dry mouth, and difficulty in
swallowing, breathing, and speaking. Descending
muscle paralysis occurs, starting with the shoulders
and progressing to upper arms, lower arms, thighs, and
then calves. Respiratory muscle paralysis ultimately
leads to death. Foodborne botulism is caused by the
ingestion of C. botulinum toxin present in contaminated food, including deliberate contamination when
the toxin is used as a biologic weapon. The incubation
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period is usually 12 to 36 hours. The case fatality rate
in the United States is 5% to 10%.
Intestinal botulism is rare and occurs mainly in
infants. It causes a striking loss of head control, constipation, loss of appetite, weakness, and an altered
cry. Intestinal botulism occurs with ingestion of botulism spores, rather than ingestion of toxin. Spores,
which may come from honey, food, and dust, germinate in the colon. The incubation period is unknown.
It is estimated to cause 5% of deaths of sudden infant
death syndrome. The case fatality rate of hospitalized
cases is less than 1%.
Wound botulism causes the same symptoms as
foodborne botulism. The incubation period is up to
2 weeks. Like intestinal botulism, this is a rare disease, caused by spores entering an open wound from
soil or gravel. Inhalational botulism would be the most
common form in the case of use of botulinum toxin
as a biologic weapon. Symptoms would the same as
foodborne botulism, but the incubation period may be
longer.
No reported cases of person-to-person transmission of botulism have been identified. Therefore,
EMS providers do not require any special equipment
to manage a patient with suspected or known botulism infection. Supportive care is advised in all cases,
including volume replacement. In the case of consumption of food suspected of being contaminated
with botulism, treatment may include gastric lavage
or whole bowel irrigation. In the case of suspected
aerosol exposure to the toxin, clothing should be removed and placed in plastic bags, and the exposed
person should shower thoroughly.
Treatment for botulism is botulinum antitoxin,
given after blood is collected to determine the specific
antitoxin needed. Antitoxin use should be considered
and administered within 1 to 2 days of exposure. Patients should be transported immediately to a center
with an intensive care unit. In intestinal botulism in
infants, equine botulinum antitoxin should not be
used. In the United States, an investigational human
derived botulinal immunoglobulin is available for infant intestinal botulism from the California Department of Health Services.116–118
Plague
Plague is caused by the bacterium Yersinia pestis. Initial signs and symptoms may be non-specific and include fever, chills, sore throat, malaise, and headache.
Tender, swollen, warm, and suppurative lymph nodes,
mainly in the inguinal area, often follow. This swollen
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lymph node is called a bubo, hence the term, bubonic
plague. Patients infected with the plague often progress to septicemia, meningitis, pneumonia, or shock.
When plague progresses to the lungs, leading to pneumonic plague, person-to-person transfer may occur
from infective respiratory droplets that are expelled
with coughing. The exposed contact subsequently develops primary plague pneumonia. Untreated plague
has a case fatality rate of 50% to 90%. If treated, the
death rate is 15%.
Plague is transmitted to humans by bites, scratches, respiratory droplets, or by direct skin contact. Bites
from infected rat fleas are the most frequent source
of transmission, but bites or scratches from cats may
also transmit plague. Airborne droplets from the respiratory tract of cats or humans infected with pneumonic plague are another source of transmission. In
case of deliberate use as a biologic weapon, plague
bacilli would be transmitted via the aerosolized airborne droplets. Direct contact with tissue or body
fluids of a plague-infected sick or dead animal can
lead to transmission to humans through a break in the
skin. The incubation period is 2 to 6 days for bubonic
plague. For primary pneumonic plague, the incubation period is shorter, typically 1 to 4 days.119,120
Prevention of infection is by controlling exposure
to infected fleas. In addition, environmental flea and
rodent control can be effective means to prevent occurrence of disease and subsequent transmission. A
vaccine for bubonic plague exists, but a vaccine for
pneumonic plague does not. The vaccine is administered in a three-dose schedule with booster doses
every 6 months. Commercial plague vaccine is no
longer available in the United States.
For patients with pneumonic plague, strict isolation
is indicated with precautions against airborne spread
until 48 hours after start of antibiotic therapy. Antibiotic therapy for bubonic or pneumonic plague is effective
if started within 8 to 18 hours of onset of symptoms.
First-line antibiotics are streptomycin or gentamicin.
Chloramphenicol is used to treat plague meningitis.
Close contacts of patients infected with pneumonic plague should be provided with chemoprophylaxis
with tetracycline or chloramphenicol for 1 week after
exposure ends. Close contacts include EMS and other
medical personnel, household contacts, and face-toface contacts. Contacts should also be placed under
surveillance for 7 days. If contacts refuse antibiotics,
they should remain in strict isolation for 7 days. Articles soiled with sputum or purulent discharges should
be disinfected.
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Y. pestis could be used as a potential biologic
weapon disseminated through aerosol spread and
leading to pneumonic plague. Many patients presenting with fever, cough, and particularly hemoptysis
in a fulminant course with a high case fatality rate
should raise suspicion to clinicians for deliberate use
as a biologic weapon.121–123
Smallpox
Two clinical forms of smallpox have been identified:
variola major and variola minor. Variola major is the
more severe form of disease with a case fatality rate
of greater than 30%, whereas variola minor is the less
severe form with a case fatality rate less than 1%.
All smallpox begins with a prodrome that lasts 2 to
4 days. The prodrome starts abruptly and consists of
fever, headache, nausea, vomiting, muscle pain, headache, and malaise.
Variola major has four principal clinical presentations: ordinary, modified, flat, and hemorrhagic.
Ordinary is the most common, occurring in 90% of
cases. Modified is mild. Flat and hemorrhagic forms
are uncommon but usually severe and fatal.124
In ordinary smallpox, after the prodrome, mucous membrane lesions (an enanthem) in the mouth
begin. This consists of red spots on the tongue, oral,
and pharyngeal mucosa that enlarge and ulcerate
quickly. Subsequently, a skin rash (an exanthem)
develops, beginning as macules on the face. The exanthem progresses from the proximal extremities to
the distal extremities and trunk within 24 hours. The
macules progress to papules, vesicles, pustules, and
then crusts. Crusts later separate, leaving depigmented skin and pitted scars. The case fatality rate for ordinary smallpox is about 30%.
Modified smallpox occurs in previously vaccinated persons. During the prodrome fever is absent,
and the illness is less severe. The skin rash is more superficial and progresses quickly, and lesions are less
numerous. This form is more easily confused with
chicken pox.
Flat smallpox has a more severe prodrome with
an exanthem that is softer and flatter and contains little fluid. Most cases are fatal. The enanthem is more
extensive, and fever remains elevated throughout the
course of illness rather than remaining restricted to
the prodromal period.
Hemorrhagic smallpox consists of a more severe
and prolonged prodrome along with extensive bleeding into the skin, mucous membranes, and gastrointestinal tract. The skin rash remains flat and does not
progress beyond the vesicular stage. Hemorrhagic
smallpox is usually abruptly fatal between the fifth
and seventh days of illness. Case fatality for hemorrhagic and flat smallpox is greater than 90%.
Variola minor produces a rash like ordinary
smallpox, but patients experience much less severe
systemic reactions.
Transmission of smallpox is via inhalation of the
virus from airborne droplets or fine particle aerosols
originating from the oral, pharyngeal, or nasal mucosa of an infected person. This usually occurs from
direct face-to-face contact within a distance of 6 feet.
Transmission could also occur from physical contact
with an infected person or with contaminated articles
through skin inoculation. Transmission from dried
skin crusts is uncommon. Smallpox is not transmissible during the incubation period. It becomes transmissible with the first appearance of rash and remains
transmissible until the disappearance of all scabs,
which is about 3 weeks. The average incubation period of smallpox is 12 days, but it ranges from 7- to
19 days.
EMS personnel should be able to identify the rash
caused by smallpox and should try to distinguish it
from other less virulent diseases, particularly chicken pox. It is important to identify smallpox because
its presence indicates a medical and public health
emergency. Differentiation can be made through the
prodrome and the rash. In smallpox, patients have a
severe febrile prodrome, whereas chicken pox produces a short, mild prodrome or even no prodrome.
In smallpox, the rash consists of deep, hard, well, circumscribed lesions at the same stage of development,
whereas in chicken pox, the lesions are superficial, not
well circumscribed, and at different stages of development. In addition to chicken pox, other conditions may
be confused with smallpox, such as herpes, impetigo,
contact dermatitis, erythema multiforme, and scabies.
Further information to differentiate these illnesses
from smallpox is available from the CDC at www.
bt.cdc.gov/agent/smallpox/.
The last two cases of smallpox were identified
in 1978, and in 1980, the World Health Organization
(WHO) declared smallpox officially eradicated from
the planet. However, two sources of smallpox virus
remain in storage and for research purposes, one in
the United States and one in Russia. Any new suspected cases of smallpox would be a medical and
public health emergency. Therefore, strict respiratory and contact isolation of confirmed or suspected
smallpox cases must be undertaken. No antiviral drug
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is approved for the treatment of smallpox, but cidofovir may be useful as a therapeutic agent and could
be used off label under an investigational new drug
protocol.
Contacts of suspected or confirmed smallpox
cases should be wearing N95 fit-tested masks, and
they should use routine PPE practices and additional precautions. All bedding and clothing should
be autoclaved or laundered in hot water with bleach.
Contacts include first responders, laundry handlers,
housekeepers, and lab personnel.
Smallpox vaccine is administered as one dose,
and success of vaccination is determined by a major
reaction at the inoculation site. The use of smallpox
vaccine as a childhood immunization was discontinued in 1972. In nonemergency situations, vaccination
is recommended for public health, hospital, and other
personnel who may need to respond to a smallpox
case or outbreak. In an emergency situation, such as
the intentional release of variola virus in a bioterrorist event, vaccination would be recommended for
those exposed to initial release, contacts of confirmed
or suspected cases, and those involved in direct care
or transportation of confirmed or suspected cases. A
number of uncommon but serious adverse reactions,
precautions, and contraindications to smallpox vaccine exist, and these should be carefully reviewed before administration of the vaccine. These matters are
well addressed at the CDC web site, www.bt.cdc.gov/
agent/smallpox/. Vaccinia immunoglobulin is available for IV administration for the treatment of adverse
reactions to smallpox vaccine. Smallpox vaccine can
be used for PEP in exposed contacts. If administered
less than 7 days after exposure, contacts generally experience the mild, modified type of smallpox if the
disease were to occur.125,126
Tularemia
Tularemia is caused by the bacterium Francisella tularensis, and its various clinical manifestations are
related to the route of introduction. All forms have
a sudden onset of nonspecific influenza-like symptoms, including high fever, cough, sore throat, chills,
headache, and generalized body aches. Sometimes,
nausea, vomiting, and diarrhea may also occur. All
forms may lead to sepsis, pneumonia, and meningitis.
The clinical forms include ulceroglandular, glandular, oculoglandular, septic, oropharyngeal, and pneumonic.128
Ulceroglandular tularemia is the most common
form. It begins at the skin site of the bite of a tick or
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fly. A papule appears that becomes pustular, later ulcerates, and finally develops into an eschar. Regional
lymph nodes become swollen, painful, and tender,
and they may suppurate and discharge purulent material. Glandular tularemia has no skin involvement,
only regional lymphadenopathy similar to that which
occurs with ulceroglandular disease. Oculoglandular
tularemia is caused by the bacillus entering the eye,
and conjunctival ulceration is followed by regional
lymphadenopathy of the cervical and preauricular nodes. Septic tularemia begins with nonspecific
symptoms of fever, nausea, vomiting, and abdominal
pain, eventually leading to confusion, coma, multisystem organ failure, and septic shock.
Oropharyngeal tularemia is caused by consumption of contaminated water or food, leading to exudative pharyngitis, which may be accompanied by oral
ulceration. Abdominal pain, diarrhea, and vomiting
may accompany this type. Regional lymphadenopathy occurs affecting the cervical and retropharyngeal
nodes.
Pneumonic tularemia may be caused not only by
inhalation of an infective aerosol from soil, grain,
or hay but also due to deliberate use of an infective
aerosol as a bioterrorist attack. The clinical presentation may be cough, pleuritic pain, and occasionally
dyspnea. Chest x-ray findings include bronchopneumonia and hilar lymphadenopathy. Despite the lungs
as the primary route of entry, it is not uncommon for
tularemic pneumonia to present as nonspecific systemic signs without respiratory symptoms, often with
a normal chest-x-ray.
Tularemia is transmitted through the skin, mucous
membranes, lungs, and gastrointestinal tract. The bacteria may be transmitted through the skin by bites, and
it may be transmitted to the oropharyngeal mucosa
and conjunctiva by contaminated water or by contaminated blood or tissue while handling carcasses of
infected animals. Through the gastrointestinal tract,
it is transmitted by ingestion of insufficiently cooked
meat of infected animals or by consumption of contaminated water. Finally, tularemia can be transmitted
to the lungs by inhalation of particles of contaminated
soil, by handling contaminated furs, or by deliberate
aerosolization of the bacterium as a biologic weapon.
The incubation period is usually 3 to 5 days but can
range from 1 to 14 days.
No documented person-to-person transmission of
tularemia has been found, even for pneumonic tularemia. Routine precautions are adequate when transporting and caring for patients. Vehicles and equipment,
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however, must be thoroughly cleaned and decontaminated after patient transport.
Although a vaccine for tularemia exists, no commercial production is as yet active, and its availability
is under review by the Food and Drug Administration.
Streptomycin is the drug of choice for treatment of
tularemia, with ciprofloxacin as an excellent alternative. Gentamicin and tetracycline are alternatives, but
the diseases may show high relapse rates when these
agents are administered. Treatment should be maintained for 14 to 21 days. In a mass casualty situation
doxycycline or ciprofloxacin for 14 days are the preferred choices for prophylaxis and should be started
as soon as possible after exposure.128,129
Viral Hemorrhagic Fevers
Viral hemorrhagic fevers are caused by different distinct families of viruses and lead to similar clinical
syndromes. In the case of bioterrorist attack, it is essential that first responders be able to recognize the
illness associated with the intentional release of the
biologic agent.
In hemorrhagic fever the initial signs and symptoms are non-specific and include high fever, headache, muscle aches, and severe fatigue. Associated
gastrointestinal symptoms of nausea, vomiting, diarrhea, and abdominal pain may appear. Respiratory
symptoms of cough and sore throat may also occur. About 5 days after the onset of illness, a truncal
maculopapular rash develops in most patients. As the
disease progresses, bleeding commonly occurs from
internal organs, the mouth, eyes, ears, and from under
the skin. Skin manifestations include petechiae and
ecchymosis. Shock, coma, seizures, and kidney failure may occur in severe cases.
Viral hemorrhagic fevers are caused by four
families of viruses: arenaviruses, bunyaviruses, flaviviruses, and filoviruses. Diseases caused by these
agents include Ebola hemorrhagic fever, Hantavirus
pulmonary syndrome, Lassa fever, Marburg hemorrhagic fever, hemorrhagic fever with renal syndrome,
and Crimean-Congo hemorrhagic fever.130 Initial
transmission occurs when humans have direct contact
with infected animals, mainly rodents, or are bitten by
a mosquito or tick vector. Once a person has become
infected, some viruses can be transmitted from person
to person, mainly by close contact with infected people, but also indirectly by objects contaminated with
infected body fluids.
Transmission of viral hemorrhagic fever mainly
occurs in the latter stage of illness when the patient
suffers vomiting, diarrhea, shock, and hemorrhage. In
the case of Ebola virus, reports of transmission within
a few days of the onset of fever have been made. The
incubation period ranges from 2 days to 3 weeks, and
no transmission has been documented during the incubation period.
No vaccine or treatment is yet available for most
of the agents causing viral hemorrhagic fever, although vaccines are available for yellow fever and
Argentine hemorrhagic fever. Ribavirin or convalescent plasma has been used for treatment with some
success. Prevention is the best method of control. To
prevent infection, contact with rodents and bites from
ticks and mosquitos should be prevented. Person-toperson transmission can be prevented by strict adherence to routine PPE practices and additional precautions. In addition, patients with known or suspected
viral hemorrhagic fever must be isolated. Although
this may be difficult in the EMS setting, the transporting vehicle can serve to isolate the patient from the
scene and while in transit.
If EMS personnel are exposed to viral hemorrhagic fever, they should be placed under surveillance
for fever. Surveillance should occur twice daily for
at least 3 weeks after exposure. In case of development of temperature above 38.3°C, patients should be
hospitalized immediately with strict isolation. WHO
and CDC have prepared an infection control manual
specific to viral hemorrhagic fever management and
control, with detailed and comprehensive strategies to
prevent spread and protect healthcare workers during
an outbreak.131–134
PART 2: EMS AND THE
COMMUNITY IT SERVES
This section describes the role and planning for
healthcare emergencies due to infectious disease,
EMS interactions with public health agencies, and
special considerations for EMS agencies in epidemics
or pandemics. EMS agencies have a responsibility in
the healthcare sector that exceeds merely emergency
response. The report “EMS Agenda for the Future”
identifies EMS at the intersection of the health care,
public health, and public safety sectors. As a key
stakeholder in community health and often the public’s first point of contact with the healthcare system
during an emergency, EMS systems must be proactive
in protecting their personnel against infectious and
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communicable disease. EMS systems must be able to
maintain this essential service during a disease outbreak and act as one of the first barriers to disease
spread within the health care system as a whole.
and any requisite training in a timely manner. Finally,
the EMS agency’s plan must include methods to coordinate the release of factual, consistent information to
the media and other public sources as required.
EMS Planning
EMS Surveillance and Mitigation
Each and every EMS agency must explore its existing
infectious disease outbreak or pandemic operational
plans and procedures. The plans and procedures must
be up to date and include a number of essential elements to be useful and functional during a true outbreak or pandemic. The plans must include the EMS
agency’s role in preparing for, mitigating, and responding to a healthcare emergency. EMS agencies should
consult with, develop, and coordinate their plans in
conjunction with other local, regional, and national
agencies and governments to ensure the EMS roles
and responsibilities are well defined and understood
by all stakeholders. The agency’s leadership and authority must also be delineated within the plan and
be consistent with local, regional, and national plans
to avoid conflict during the actual emergency. If not
already in place, the EMS agency should adopt an incident command process or other similar system used
by other public service agencies.
Each EMS agency should also develop and participate in training exercises that will prepare the agency
and its personnel for their role in local, regional, and
national infectious disease emergencies. These exercises allow each agency to exercise its plans and
procedures and determine how it functions together
with those from other public service and healthcare
agencies. The exercises also allow individual EMS
providers to better understand their respective roles
during an emergency. Most importantly, exercises allow EMS leaders and personnel to develop a personal
relationship with others within the public service and
healthcare systems that can enhance communication
during an actual emergency.
Effective communication and dissemination of
information is typically a major obstacle during any
healthcare emergency or disaster. To avoid ineffective
or erroneous communication between stakeholders,
plans must include a defined process to gather, update,
and disseminate factual information to all relevant
stakeholders. In the EMS setting, this must include
clinical standards, treatment protocols, and any procedures specific to that emergency. The plan must also
include just-in-time training methods to ensure all
EMS leadership and providers receive this information
EMS agencies and their providers are often the first
point of contact between the public and the healthcare system during an emergency. This contact may
be the first opportunity to identify a potential threat
and mitigate that risk. During the SARS outbreaks
in Toronto and Taipei, EMS providers were among
the first healthcare workers infected with the virus.2,3
Interfacility patient transport by EMS agencies was
also identified as a cause of further spread of SARS
between hospitals.2,36
To mitigate the risk to providers and the healthcare system, EMS agencies must quickly adopt and
implement a multitude of surveillance, screening, and
mitigation strategies to prevent further disease spread.
During the SARS outbreaks in Toronto, all EMS personnel were screened, and a surveillance system monitored all potentially exposed personnel.4 A series of
work and home quarantine measures were also implemented to prevent depletion of the EMS workforce
and ensure a level of sufficient staff to maintain emergency response capabilities. In addition, call-taking
procedures were modified to screen all calls to an
EMS dispatch center for any sign of communicable
or infectious disease. Responding personnel would
be advised of any call that screened positive. Finally,
a provincial government developed and deployed an
innovative EMS command, control, and tracking system to mitigate the risk of iatrogenic spread of SARS
among healthcare facilities, healthcare workers, and
patients due to interfacility patient transfers.135 All
EMS agencies should have plans to provide providerand agency-level strategies for surveillance, screening, and mitigation to protect both their personnel and
the public at large.
Local and regional EMS agencies should identify
the roles that they play in ongoing disease surveillance to quickly identify and mitigate the risk of disease once it occurs. Potential roles for EMS include
real-time monitoring and analysis of patterns in call
volume, call type, presenting complaint, location, and
any other disease-specific factors for which data are
routinely available at EMS dispatch centers. These
data, when used alone or in conjunction with other
healthcare data, can help identify variations from nor-
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Individual Chief Complaint Protocols
12/8/08 3:01:13 PM
mal or expected patterns in community health-seeking
behavior. These temporal and spatial fluctuations may
be the first evidence of a potential threat to community health. EMS agencies can also play a collaborative
role in a multiagency, multijurisdictional initiative to
identify persons or groups at risk based on location
and points of contact with the healthcare system. This
can help public health and other authorities identify
and track patients at risk of exposure and prevent further spread of disease.
Continuity of EMS Operations
EMS agencies should include, in their preparedness
plans, a contingency to allow EMS to maintain its
ability to respond to routine emergencies while meeting the needs of a major infectious disease outbreak.
EMS will likely experience an increased demand for
service while facing potential loss of trained personnel due to illness and absenteeism. In addition, the
agency may face increased emergency department
(ED) diversions or offload delays and a shortage
of equipment and supplies. Both limit the agency’s
ability to maintain adequate resources to meet its
existing service mandate. Finally, it is likely that a
healthcare emergency due to infectious disease will
be ongoing and of many weeks duration, placing a
prolonged strain on EMS operations, personnel, and
resources.
EMS should take into account the prolonged nature of this potential emergency when planning. Local, regional, and national EMS organizations should
have a plan to shift personnel between jurisdictions
and augment any inadequate numbers in EMS workforce. An adequate supply of essential equipment,
supplies, and services must be available should the
supply chain be interrupted during an emergency.
Finally, an effective, reliable communication system
and set of protocols must be available to EMS, public
service, and healthcare agencies to ensure all stakeholders receive timely information and are aware of
diversion and capacities at local and regional levels.
Legal Authority
It is not typically possible for routine EMS policies and
procedures to take into account any possible situation
or scenario. This is particularly true in the setting of a
healthcare emergency or disaster. The emergency plans
developed by EMS agencies should include approved
policies and procedures that enable agencies to devi-
ate from routine procedures to respond to a disaster or
similar situation.
The plans should identify the legislative authority, administrative rules and regulations, and liability protection to support the role of EMS providers
during an infectious disease outbreak or other public
health emergency. The legal authority should permit
EMS agencies and their providers to modify established treatment procedures to respond to the evolving role of EMS during the emergency, while assuring appropriate medical direction, education, and
quality assurance measures are in place. The plans
should also include authority and ability to move and
license EMS assets, such as vehicles and personnel,
if restrictions in movement of the general public are
in place.
Clinical Standards and Protocols
EMS standards and treatment protocols may require
rapid and repeated modification during an infectious
disease outbreak as more information on the outbreak
becomes available. Each EMS agency must have physician medical direction to provide oversight and input regarding these modifications and rapid dissemination and training methods to ensure providers are
appropriately informed and prepared to deal with the
outbreak.
Medical directors and EMS agencies should also
have methods to communicate with other healthcare
agencies to ensure new EMS standards and protocols
are consistent with those in other healthcare sectors.
The office of the medical examiner or coroner should
be contacted to help identify protocols and processes
to manage facilities and outpatient facilities, and determine the need for EMS-based treat-and-release protocols that do not require patient transport to a healthcare facility in the setting of unusual circumstances
such as mass gatherings, outbreaks, or other instances
where health-seeking behaviour may increase.
Protecting EMS Workforce
Well-Being
EMS is a key component of any critical infrastructure, and EMS personnel would experience additional
workplace stress during an outbreak or other related
healthcare emergency. The EMS agency must have
in place strategies to protect the EMS workplace and
their families to maintain EMS operations during an
outbreak.
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EMS agencies must ensure that all EMS personnel use routine PPE practices and additional precautions (when indicated) and ensure the necessary infrastructure is in place to promote safe working practices
to mitigate the risk of disease. Finally, EMS agencies
must make available, at all times, an adequate amount
of appropriate protective equipment and related supplies designed to prevent disease.
Where risk mitigation programs exist, EMS agencies must ensure that EMS personnel receive priority
access to these programs. In the event of a vaccine- or
medication-preventable outbreak, EMS agencies must
have an established plan to provide vaccination or appropriate prophylactic medication to all EMS personnel in a timely manner. In the event of potential contact
with an infectious disease, EMS agencies must have
mechanisms in place to determine if isolation or quarantine are necessary and provide suitable resources for
this. Finally, EMS personnel and their families must
have available the necessary support services, including counseling and mental health, both during and after an infectious disease outbreak.
CLI NI C A L VIGNE T T E
The regional EMS communications center receives
a call from a young boy. He states “I came home
and found my mother on the floor! She is confused!
Please help!” The EMS call-taker asks, “Are you close
to her?” “Yes” he replies. “Is she breathing?” “Yes, he
replies.” The call-taker tells the boy, “Alright, help is
on the way” and forwards the call information to
the vehicle dispatcher.
The call-taker continues his call-taking. “Does
she have a fever, cough, or any other sign of illness?”
The boy replies, “She feels very hot! She has been
sick since coming back from a trip.” The call-taker
refers to the pre-arrival instructions and his infection control protocol. “Is anyone else in the home
sick?” “Yes, my father and sister are also sick with a
cough and diarrhea.”
The call-taker advises the dispatcher to notify
the first responders and EMS crew to use personal
protective equipment to ensure they are protected
against infectious disease.
The first responders and EMS crew arrive at the
same time. The EMS crew advises the first responders to remain outside the home until they assess
the scene and the patient. Both paramedics put on
mask, gloves, and gown before making patient contact. In keeping with their infection control protocol,
they bring only limited equipment into the house.
They find the patient lying on the floor, eyes
closed, and not responding to questions. Her respirations appear labored. A fecal odor permeates the
room. Paramedics take the patient’s vital signs: pulse
130/minute and regular, respirations 32/minute and
labored, blood pressure 102/80 mmHg, SpO2 86%,
354
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and temperature of 40.4 degrees Celsius. Auscultation of the chest shows wheezes throughout with
prolonged expiration. They find no rash or other lesions on the skin.
While one paramedic delivers high-flow oxygen
by a mask specially designed to prevent respiratory
droplet spread, his partner establishes an intravenous line and initiates a crystalloid bolus.
The first responders are asking the paramedics
if they should enter the home and assist in packaging the patient for transport. The paramedics replies “No, stay outside but bring our stretcher to
the door and have everyone move away from the
building” in order to prevent unnecessary exposure
of other providers to the patient.
As they prepare the patient for transport,
paramedics contact EMS dispatch to determine a
receiving hospital. The closest hospital is a community hospital less than 5 minutes from the
home. Regional EMS protocols indicate patients
with infectious or communicable disease should
be transported to one of the designated regional
hospitals equipped with infection control facilities
unless the patient has an immediate threat to life
requiring emergent intervention not available in
the field. EMS dispatch advises the crew to bypass
the local hospital and transport to the regional
hospital. The EMS dispatch also notifies the receiving facility of the patient, advising them to prepare staff to receive the patient. Finally, EMS dispatchers follow regional protocols and notify the
public health authorities of an infectious disease
affecting several people in the same location, and
Individual Chief Complaint Protocols
12/8/08 3:01:13 PM
dispatches additional EMS resources to assess the
other family members.
The paramedics transfer the patient to the
stretcher and load her into the ambulance. In keeping with protocol, the first responders do not assist
the paramedics. En route, the paramedics contact
the receiving facility. “We have a 38 year old female
who just returned from China with fever, cough, and
confusion. She has is tachycardic and hypovolemic,
altered level of consciousness, and increased work of
breathing. We are not intubating her due to an active respiratory disease. Our ETA is 8 minutes. Please
prepare your infection control room and for possible
intubation.” The transport to hospital is uneventful.
Paramedics arrive, unload the patient, and are
directed through a separate entrance to a dedicated resuscitation room equipped with negative
pressure ventilation. Emergency department staff
are wearing full PPE and prepare to intubate the
patient.
The paramedics return to their ambulance. They
contact EMS communications and inform the dispatcher they are not available until their vehicle and
equipment is properly decontaminated. The crew
decontaminates the vehicle and equipment using
established EMS procedures, removes their PPE,
and returns to service.
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